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Home My WebLink About02-18-14 � 1505610105 REV-1500 EX�oz_��>�F�, �: OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes " �"�`"�� County Code Year File Number f aE�E,�E PO BOX 28o6oi INHERITANCE TAX RETURN Harrisburg PA l�iz8-o6oi RESIDENT DECEDENT ��"�3'L�`�� ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 03/15/2013 08/21/1931 DecedenYs Last Name Suffix DecedenYs First Name MI Coy Leroy W (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW � 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) p 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) � 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust � 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Gregory R. Reed, Esq. (717)238-0434 REGISTER OF WILLS USE ONLY First Line of Address R.. n 3120 Parkview Lane ��' " �'—.' , �- ;.� ' :_:: �,--; ; . , . Second Line of Address - ti=-� - r G� � - City or Post Office State ZIP Code DA�f,ILED ' ,�- , , _ � , _. , Harrisburg PA 17111 � � ��:� �� r; T3 �'� �_��7 �7 Correspondent's e-mail address: --..3 Under penalties of pery'ury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true, rrect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA U OF PERSON R NSI L FOR FILING RETURN DAT �� ADD SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J � 1505610205 REV-1500 EX(FI) DecedenYs Social Security Number �ecedent's Name: Leroy W. COy RECAPITULATION 1. Real Estate(Schedule A). . . . .... .. . .. . . .... . .... ..... . ... .... ... . . . . . L 2. Stocks and Bonds(Schedule B) .. . . .. ....... . . ...... ... . . .. . . . . .... . .. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . . . . . 3. 4. Mortgages and Notes Receivable(Schedule D). ... ..... . . . .. . . . . ..... .. . . 4. 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . . .. 5. 23,402.28 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... .. . . 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... . . .. 7. 8. Total Gross Assets(total Lines 1 through 7)... . . ......... . . .. .. . . . .. . . . . 8. 9. Funeral Expenses and Administrative Costs(Schedule H).... . . .. .. . . . .. . . . . 9. 23,402.28 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I). . .. . . . .... . . .. 10. 11. Total Deductions(total Lines 9 and 10). .. . ..... . .... . . . ... . . ... . . ... . . . 11. 23,402.28 12. Net Value of Estate(Line 8 minus Line 11) . . .. .. . .... . . . . .. . . . ....... . . . 12. 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) .. .... . . .. . .... . . . . .. . .. 13. 14. Net Value Sub'ect to Tax Line 12 minus Line 13 14. 0.00 1 � ) ...... . .. . . ... ..... . .. . . TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 15. 16. Amount of Line 14 taxable at lineal rate X A_ 16. 17. Amount of Line 14 taxable at sibling rate X.12 �� 18. Amount of Line 14 taxable at collateral rate X.15 �8• 19. TAX DUE . ... ...... ....... . . .. . ......... . ... ....... . . . . ....... .. . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C� Side 2 � 1505610205 15�5610205 � REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: DECEDENT'S NAME Leroy W. Coy STREETADDRESS 231 Strohm Road ��Ty STATE ZIP Shippensburg PA 17257 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) l�) 2. CreditslPayments A.Prior Payments B.Discount Total Credits(A+B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... ❑ � b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ � c. retain a reversionary interest .............................................................................................................................. ❑ � d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ � 2. If death occurred after Dec. 12,1982,did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................................. ❑ � 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ � 4. Did decedent own an individual retirement account,annuity or other non-probate property,which contains a beneficiary designation? ........................................................................................................................ ❑ � IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN, For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the suroiving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: . The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent or a stepparent of the child is 0 percent�72 P.S.§9116(a)(1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in(72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-15o8�X+(o8-iz) � SCHEDULE E . � pennsylvania DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC. INHERIfANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Leroy W. Coy ��-\•3 -C3�� Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH �. 1981 Pick-up Truck-(Exhibit"A") 1,300.00 2, Citizens Bank Checking Account 36100720772-(Exhibit"B") 20,405.77 3. Refund from Shippensburg Health Care Center-(Exhibit"C") 1,696.51 TOTAL(Also enter on Line 5, Recapitulation) $ 23,402.28 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+ (08-13) � ,� pennsylvania SCHEDULE H DEPARTMENTOFREVENUE FUNERAL EXPENSES AND INHERITANCETAXRETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Louvain J. Shultz 2-1 —��—L?,5a DecedenYs debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES; 1. B. ADMINISTRATIVE COSTS; 1. Personal Representative Commissions: 2,000.00 Name(s)of Personal Representative(s) Joyce E. Gruver Street Address 231 Strohm Road _ City Shippensburg State PA_ZIp 17157 Year(s)Commission Paid: 2013 2. Attorney Fees: 2,000.00 3. Family Exemption; (If decedent's address is not the same as claimant's,attach explanation.) Claimant N/A Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 143.50 5. Accountant Fees: 6. Tax Return Preparer Fees: �• Spring Creek to SHCC(last illness) 129.00 s. DPW lien-(Exhibit"D") 19,129.78 TOTAL(Also enter on Line 9, Recapitulation) $ 23,402.28 If more space is needed,use additional sheets of paper of the same size. REV-1513 EX+ (01-10) �' pennsylvania SCHEDULE � ' DEPARTMENT OFREVENUE �� WHERITANCETAXRETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Leroy W. Coy ��"�3—L�� RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1• Joyce E.Gruver Daughter Entire Estate 231 Strohm Road,Shippensburg,PA 17157 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II— ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. _ __----- ' �°�``.�G�'� �.fJ��- ��. � , /� " �!� � �I �� ~n- �� t - c � c�� L��? �� .-C��d.�� j �� a 1�11�� , ' � � j � � � �� i��- ,l� �''; ` _� �'� ��.^.�d�z` .�', ��'�� --a ��=� s' ..z� �� y �-� ��- fu ,� `� a� p 2�.: .�G�� C l4�q8�' r'3�3� �/�r . �� `�� - � -a'��.-- �`�- -� � � �, .� �` �� ,��'-- .�� - C� C �� ' � ' �.G' ��•+��azd�,� !�h��;,� ��3' a'��- � � �'ti Q2IO�fl2I S.2I�I�IO.LSf1� �� a . i �� {� � � �� g� � �. :,� 19�^'�`g..�� ,,� . l `,�^.^ �:i��~��.• ' � �.� � .�. . ��:� �� . . . �w+� ' �� . r,`,. � , ��/''� ' �/ ^1 ,,�4�\ .. . . �;� �� . ' � ' � p; O k �I� J .�. Ip p r. � .'• 8 ' �� -- 'y,\; Q � � � _ � �; w d ._ G W � � � O 0. � � ' y ' � � ;° S � i � 'f �- 9 x F ,�, J N �n m .� a I V - a Q � z ! ".� s.: - � rx � � � O R Q I (> � w w �; o � � , ... z x � � ' t�i: -_ ss z � o u i p °z H � a � W �` W � ' � > � o # � � z a o � � F " T Q � � U O -. y u. U 2' U ia W � o � � = w C� � L O F '. � �, � o I N ¢ U , = 3 � � N .� �1�+ V I 7y11�C � �o � �. Q a 1-voa��W 60/E MaN LOOE6 � I • � � One Citizens Drive ROP112 Riverside, RI 02915 April 3, 2013 Gregory R. Reed Attorney At Law 3120 Parkview Lane Harrisburg PA 17l 11 Estate of: LEROY W COY Date of Death: Mar 15, 20]3 SSN: 200-24-1073 Dear SidMadam: In accordance with your request,the attached information sheet has been provided in the above decedent's name as of his/her date of death. For Installment Loans or Line of Credit accounts,contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-877-579-2667 Sincerely, � ��a �t�c�� Kristen L. Petrucci Decedent Account Processing REF#: 58775? � � Account Number 6100720772 Account Title LEROY W COY Date Opened 6/16/1975 Account Type Checking Principal Balance as of DOD $20405.77 Interest from Last Posting to DOD $ .00 Account Balance as of DOD $20405.77 YTD Interest to DOD $ .00 Statements Page 1 of 1 STATEMENT Shippensburg Health Care Center Resident: Coy, Leroy(01929 ) 121 Walnut Bottom Rd. Location: - Shippensburg, PA 17257-9005 Statement Date: 9/1/2013 • (717) 530-8300 ALL TRANSACTIONS PROCESSED AFTER Aug 31, 2013 WILL APPEAR ON YOUR NEXT STATEMENT Joyce Gruver 231 Strohm Rd Shippensburg, PA 17257 Amount Due $0.00 PLEASE DETACH AND RETURN WITH YOUR PAYMENT Amount Enclosed $ Shippensburg Health Care Center Resident: Coy, Leroy(01929 ) 121 Walnut Bottom Rd. Location: - Shippensburg, PA 17257-9005 Statement Date: 9/1/2013 (717) 530-8300 Effective Date Description Units Unit Amount Amount BALANCE FORWARD ($1,696.51) 2/28/2013 Adjust Patient Liability 1 $1,696.51 $1,696.51 BALANCE DUE $0.00 Please remit payment upon receipt. We accept Cash, Checks, Discover, Mastercard, Money Orders, Visa and ACH from Checking and Savings accounts. Please note interest may be charged on past due balances but may not show on the statement. Thank You. https://www4.pointclickcare.com/admin/reports/statements us.jsp 8/8/2013 __ •• pennsylvania '� ' DEPARTMENT OF PUBLIC WEIFARE April 3, 2013 GREGORY R REED ESQUIRE 3120 PARKVIEW LANE HARRISBURG PA 17111 Re: Leroy Coy CIS #: 860350969 SSN: ###-##-1073 Date of Death: 03/15/2013 Dear Attorney Reed: Piease be advised that the Department of Public Welfare maintains a claim in the amount of�22,328.24 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $17,932.61, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $4.395.63, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, l - Karen H. Peterson Claims Investigation Agent 717-772-6615 717-772-6553 FAX Enclosure Bureau of Program Integrity � Division of Third Party Llability � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486 LAST WILL AND TESTAMENT OF LEROY W. COY KNOW ALL MEN BY THESE PRESENTS, That I, LEROY W. COY, currently of Lower Swatara Township, Dauphin County, Pennsylvania, do make, publish and declare this instrument to be my Last Will and Testament, hereby revoking and making void any and all former Wills by me at any time heretofore made. FIRST—I direct the Executrix hereof to pay all my just debts, funeral expenses and costs of administration as soon as conveniently may be done after my death. I further direct the Executrix hereof to pay all inheritance, estate, transfer and succession taxes which may be levied or assessed upon any property which is included as part of my gross estate for the purpose of any such tax. SECOND —I give, devise and bequeath all the rest, residue and remainder of my estate, both real and personal, to my stepdaughter, JOYCE E. GRUVER. THIRD — I appoint my stepdaughter, JOYCE E. GRUVER, to be the Executrix of this, my Last Will and Testament. I do hereby give to the Executrix hereof full power, discretion and authority at any time or times to sell, at private or public sale, mortgage, lease, pledge, exchange or otherwise deal with or dispose of the property comprising my estate upon such terms as deemed best, to settle and compound any and all claims in favor of or against my estate as deemed best and, for any of the foregoing purposes, to make, execute and delivery any and all deeds, mortgages, contracts, leases, bills of sale or other instruments necessary or desirable therefor. �=� °� � �� 2 LWC W-1 W-2 LASTLY—I direct that no fiduciary appointed by this, my Last Will and Testament, shall be required to give Bond and that if, notwithstanding this direction, any Bond is required by any law, statute or rule of court, no Surety shall be required thereon. IN WITNESS WHEREOF, I have set my hand and seal to this, my Last Will and Testament, consisting of two (2)pages on the margin of which (except this page) I have affixed my initials this��f-�'day of� , A.D. 2012. ";:L.---�. ��' �� LEROY W. COY Signed, sealed, published and declared by LEROY W. COY, the above named Testator, as and for his Last Will and Testament. This document was executed at his request and in his presence, and in the presence of each of us, and we have hereunto subscribed our names as attesting witnesses. � ,� �� v�� .......�'� ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA :ss COUNTY OF DAUPHIN I, LEROY W. COY, testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by LEROY W. COY, the testator, this l�' ��day of_�(��, 2012. �� - � LEROY W. COY, Testator �` � _ ��, , Notary Public NOTARIAL SEAL SARA E REED Notary Public SWATARA TWP.,DAUPHIN COUNTY My Commisslon Expires Apr 29,2013 AFFIDAVIT COMMONWEALTH OF PENNSYVLANIA :ss COUNTY OF DAUPHIN We, Gregory R. Reed and Caleb M. Reed, the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the testator sign and execute the instrument as his Last Will; that the testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testator signed the will as a witness; and that to the best of our knowledge the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by Gregory R. Reed and Caleb M. Reed, witnesses, this�---day of � � , 2012. , Witness � .� , r',f� �� - � Witness \� � ,'` t Notary Public NOTARIAL SEAL SARA E REED Notary Public SWATARA TWP., DAUPHIN COUNTY My Commission Expires Apr 29, 2013 ��re��r� �. Qee� Attorney at Law 3120 Parkview Lane Harrisburg, Pennsylvania 17111 Phone: (717)238-0434 * Fax: (717)238-8469 Email: lawoffice(c��,reedpalaw.com Joshua A. Reed, Esq. February 13, 2014 Lisa Grayson Register of Wills 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Leroy W. Coy, Deceased File No. 21-13-0352 Dear Ms. Grayson: Enclosed find the original and two (2) copies of a Inheritance Tax Return and a check in the amounts of$15.00. Please file the original and return a"clocked" copy in the enclosed self- addressed stamped envelope. Very truly� yc,urs, ' �. ��''�� Gregory R. Reed GRR/abm . _. _- _, a-3 Enclosures �_ .-, _ -` _._, �, �,: _ � „ ' �' k.. ti�, -- Cl� - � _ _ �:�:_ -._� �J'� -__' , --i _i� _' v .., t..7 �-�'t �� E'� �fJ 1 � � � � � � ��• � � � � � � � � _ � y � �' o � � � � � � � o,� � � W � .� �